What is the appropriate medication management approach for an adult patient with a history of substance abuse or dependence?

Medication Management for Adults with Substance Use History

For patients with a history of substance abuse or dependence, avoid prescribing controlled substances with abuse potential—specifically avoid phentermine, diethylpropion, benzphetamine, phendimetrazine, and opioid analgesics unless absolutely necessary, and use SSRIs as first-line for anxiety management. 1, 2

Immediate Assessment Priorities

When managing any medication regimen in patients with substance use history, first determine:

• Current substance use status: Active use, early recovery, or sustained remission 1
• Specific substances involved: Different substances carry different relapse risks (heroin, methamphetamine, and crack cocaine have intrinsically high harm potential) 1
• Physical dependence risk: Particularly critical for benzodiazepines and alcohol, where withdrawal can be life-threatening with seizures and autonomic instability 2
• Polysubstance use patterns: Use urine drug testing when clinically indicated to identify concurrent substance use 1

Medications to Avoid

Controlled substances with abuse potential should be avoided:

• Sympathomimetic appetite suppressants (phentermine, diethylpropion, benzphetamine, phendimetrazine): These are Schedule IV controlled substances and explicitly contraindicated in patients with history of substance use disorder 1
• Opioid analgesics: Patients with active or previous substance abuse (including alcoholism) and family history of substance abuse are more likely to misuse and abuse opioids 1
• Benzodiazepines: High abuse potential and dangerous withdrawal profile 2
• Tramadol: Despite lower abuse potential than traditional opioids, it still carries dependency risk and can cause serotonin syndrome when combined with SSRIs/SNRIs 1

Safe Medication Alternatives

For Anxiety Management

SSRIs are first-line treatment due to strong efficacy evidence and no abuse potential: 2

• Escitalopram
• Sertraline
• Paroxetine
• Fluvoxamine

For Pain Management

When pain management is necessary in patients with substance use history:

• Non-opioid analgesics first: NSAIDs, acetaminophen, topical agents 1
• If opioids are unavoidable: Collaborate with palliative care, pain, and/or substance use disorder specialists to determine optimal approach 1
• For patients on buprenorphine maintenance: Continue usual buprenorphine dose and use short-acting opioid analgesics for breakthrough pain only when absolutely necessary 3

For Weight Management

If obesity treatment is needed:

• Metformin: Widely available, inexpensive, no abuse potential, associated with 3% weight loss 1
• GLP-1 receptor agonists: No abuse potential (though currently in shortage) 1
• Avoid: Phentermine and other sympathomimetic amines due to abuse potential and explicit contraindication 1

Active Substance Use Disorder Management

For Opioid Use Disorder

Buprenorphine/naloxone (Suboxone) is the preferred medication-assisted treatment: 3

• Target dose: 16 mg daily for most patients
• Only initiate during active withdrawal (>12 hours from short-acting opioids, >24 hours from extended-release, >72 hours from methadone) to prevent precipitated withdrawal 3
• Confirm withdrawal using Clinical Opiate Withdrawal Scale (COWS) 3
• Combine with counseling and behavioral therapies 3

For Benzodiazepine Dependence

Planned gradual taper over 8-12 weeks with conversion to long-acting benzodiazepine: 2

• Assess withdrawal risk: history of seizures, concurrent alcohol use, duration of use, daily dose 2
• Weekly visits initially to monitor withdrawal symptoms and medication adherence 2

For Cannabis Use Disorder

Brief psychosocial intervention is first-line treatment: 2

• Use validated screening tools like ASSIST to quantify severity 2
• Incorporate motivational principles, individualized feedback, and advice on reducing or stopping use 2
• Refer to mutual help groups (Narcotics Anonymous, SMART Recovery) 2

Critical Prescribing Principles

When any medication is necessary:

• Start at lowest possible dose 1
• Use immediate-release formulations initially with frequent reassessment 1
• Monitor closely for signs of misuse or diversion 1
• Document risk-benefit discussion in medical record 1
• Consider involving addiction specialists for complex cases 1, 3

Common Pitfalls to Avoid

• Never initiate buprenorphine while patients are under influence of full opioid agonists—this causes precipitated withdrawal 3
• Never abruptly discontinue opioids or benzodiazepines in physically dependent patients—taper gradually 1, 2
• Do not assume all substance use carries equal risk—stratify into hazardous use, abuse, or dependence and tailor intervention intensity accordingly 1
• Avoid prescribing medications that lower seizure threshold (like tramadol) in patients with benzodiazepine or alcohol withdrawal risk 1